Previous exposure to violence among emergency department patients without trauma-related complaints: A cross sectional analysis.

INTRODUCTION: The Emergency Department (ED) is a critical setting for the treatment of acute violence-related complaints and violent victimization is associated with numerous long-term negative health outcomes. A trauma-informed care framework can prevent re-traumatization of victims within the healthcare setting, but currently there are insufficient mechanisms to detect previous exposures to community violence within the ED. The current study sought to determine the prevalence of community violence and characterize the types of violence exposures among adult ED patients without trauma-related complaints to determine if there may be a need for expanded screening for previous exposure to violence for ED patients. METHODS: This was a prospective cross-sectional observational study of adult ED patients without a trauma-related chief complaint at an urban public hospital. Adult patients were approached by trained research staff and answered questions adapted from the Survey of Exposure to Community Violence (SECV), which measures lifetime exposure to community violence, including both witnessing and victimization. The SECV was modified for clarity, brevity, and to assess exposure to violence within the previous 3 months and 3 years from enrollment, in addition to lifetime exposure. Enrollment occurred from June 2019 to September 2022 with a 19-month gap due to the COVID-19 pandemic. Demographics and results within SECV domains were analyzed using descriptive statistics. Comparisons between males and females in types of violence experienced during one's lifetime were made by fitting logistic regression models adjusting for age. RESULTS: A total of 222 respondents completed some or all of the modified SECV. Ages ranged from 19 to 88, with 47.7% of respondents identifying as female and 50.9% as male. Of all respondents, 43.7% reported directly witnessing violence during their lifetime, 69.4% being personally victimized by violence, and 55.4% personally knowing someone killed by a violent act. Of those personally victimized, 47.4% occurred within the preceding 3 years and 20.1% within 3 months. Among all respondents, lifetime victimization was reported in the following domains: slapping, hitting, or punching (45.9%); robbings or muggings (33.8%); physical threats (28.8%); verbal or emotional abuse (27.5%); being shot at (18.0%); uncomfortable physical touch (15.3%); forced entry while home (14.4%); sexual assault, molestation, or rape (13.5%); or being attacked with a knife (13.5%). Comparing male and female respondents, 63.5% of females and 76.6% of males reported any violent victimization over their lifetime (aOR 1.88; 95% CI 1.04-3.43). Additionally, 31.7% of females and 56.3% of males reported witnessing violence (aOR 2.86; 95% CI 1.64-5.06). Males were more commonly exposed to physical violence, violence with weapons, and threats while females more commonly reported sexual assault, molestation, and rape. CONCLUSION: Both lifetime and recent exposure to community violence was common among adult ED patients without trauma-related complaints. Broader adoption of a trauma-informed care framework and the development of efficient ED screening tools for previous exposure to trauma is reasonable in areas where community violence exposure is highly prevalent.

Association of Patient English Proficiency and Diagnostic Imaging Acquisition in Emergency Department Patients with Abdominal Symptoms.

BACKGROUND: Patients with limited English proficiency (LEP) are at risk for communication barriers during medical care in the United States compared with English-proficient (EP) patients. It is unknown how EP affects the utilization of advanced diagnostic imaging (ADI) in the emergency department (ED). OBJECTIVE: The aim of this study was to compare the acquisition and findings of ADI in EP and LEP patients with abdominal symptoms. METHODS: We conducted a retrospective analysis of adult ED patients from January 2015 to January 2016. Patients were divided into EP and LEP cohorts. Logistic regression models incorporated language proficiency, interpretation method, and demographic characteristics. We determined crude and adjusted odds ratios (ORs) for the acquisition of ADI, defined as either computed tomography or ultrasound, and the proportion with actionable findings. RESULTS: In 3324 encounters (2134 EP; 1190 LEP), LEP patients were older (46.3 years vs. 43.8 years), more likely to be female (66.7% vs. 51.5%), and preferred Spanish (91.4%). ADI was obtained in 43.5% of EP and 48.1% of LEP. Adjusting for age, sex, and interpretation method, the OR was 1.09 (95% CI 0.90-1.32). There were no significant associations between interpretation type and acquisition of ADI. The proportion with actionable findings were similar in EP and LEP cohorts (29.6% vs. 26.7%). CONCLUSIONS: Accounting for demographic differences, ADI acquisition was similar for ED patients with and without LEP. Further research is needed to determine optimal interpretation modalities in this setting to prevent unnecessary imaging.

A cross-sectional analysis of fentanyl analog exposures among living patients.

Background: Synthetic opioids, including fentanyl analogs, contribute to an increasing proportion of opioid-related deaths. Highly potent analogs pose an increased risk for fatal overdose. The prevalence of fentanyl analog exposures in patients with known opioid exposure is unknown.Objective: The purpose of this study was to determine the exposure prevalence for fentanyl analogs in living patients with positive urine screens for opiates or fentanyl.Methods: This was a cross-sectional analysis of urine high performance liquid chromatography/tandem mass spectroscopy (HPLC-MS/MS) results from patients with a positive urine screen for opiates or fentanyl at a large public healthcare system in Chicago, Illinois. Samples with positive screens were non-continuously tested by HPLC-MS/MS for 5 selected months in 2018 and 2019.Results: A total of 219 urine samples which screened positive for fentanyl or opiates underwent HPLC-MS/MS testing. At least one fentanyl analog was detected in 65.3% (n = 143) of samples with 26.0% (n = 57) testing positive for multiple analogs. The most common analogs, intermediates, or metabolites were: 4-ANPP (n = 131); 2-furanylfentanyl (n = 22); acryl fentanyl (n = 21); butyrylfentanyl (n = 15); cyclopropylfentanyl (n = 15); and carfentanil (n = 13). Of samples which screened positive for fentanyl (n = 188), 70.2% (132) tested positive for at least one fentanyl analog. Of samples which screened negative for fentanyl but positive for opiates (n = 31), 35.5% (n = 11) tested positive for fentanyl analogsConclusion: Fentanyl analog exposure is common in patients with positive urine screens for fentanyl or opiates. Screening living patient samples for synthetic opioids has future toxicosurveillance implications and these data underscore the increased risks from illicit opioid use.

Treatment of acute naloxone-precipitated opioid withdrawal with buprenorphine.

Naloxone is a frequently utilized and effective treatment to reverse the life-threatening effects of illicit opioid intoxication. Excessive naloxone dosing in these circumstances, however, may lead to naloxone-precipitated opioid withdrawal in individuals with opioid dependence. Buprenorphine, a partial mu-opioid agonist, is increasingly utilized in the Emergency Department (ED) for the treatment of opioid withdrawal syndrome but little is known regarding its utility in cases of naloxone-precipitated opioid withdrawal. We report a case of naloxone-precipitated opioid withdrawal that was effectively treated with sublingual buprenorphine. An older male was brought into the ED with signs and symptoms of opioid toxicity that was successfully treated with pre-hospital naloxone by Emergency Medical Services. He had a clinical opioid withdrawal scale (COWS) or 10 with abdominal cramping and unintentional defecation. After a discussion of treatment options and possible adverse effects with the patient, the decision was made to administer 4 mg/1 mg of sublingual buprenorphine/naloxone film. The patient reported a rapid improvement in symptoms and at 30 min posttreatment, his COWS was 4. His COWS decreased to 3 at 1 h and this was sustained for 4 h of observation. The patient was subsequently discharged to a treatment facility for opioid use disorder. This case highlights the potential of buprenorphine as a treatment modality for acute naloxone-precipitated opioid withdrawal. Due to the risks of worsening or sustained buprenorphine-precipitated opioid withdrawal, further research is warranted to identify patients who may benefit from this therapy.

Emergency Department Patient Burden from an Electronic Dance Music Festival.

BACKGROUND: Electronic dance music (EDM) festivals are increasingly common and psychoactive substance use is prevalent. Although prehospital care can obviate the transfer of many attendees to health care facilities (HCFs), little is known regarding the emergency department (ED) burden of patients presenting from EDM festivals. OBJECTIVES: This study describes the patient volume, length of stay (LOS), and presenting complaints of patients from a 3-day EDM festival in close proximity to an area ED. METHODS: Medical charts of patients presenting to one HCF from an EDM festival were reviewed for substances used, ED LOS, and sedative medications administered. Additionally, preparedness techniques are described. RESULTS: Over the 3-day festival, 28 patients presented to the ED (median age 21 years; range 18-29 years). Twenty-five had complaints related to substance use including ethanol (n = 18), "molly" or "ecstasy" (n = 13), and marijuana (n = 8). Three patients required intensive care or step-down unit admission for endotracheal intubation, rhabdomyolysis, and protracted altered mental status. The median LOS for discharged patients was 265 min (interquartile range 210-347 min). Eleven patients required the use of sedative medications, with cumulative doses of 42 mg of lorazepam and 350 mg of ketamine. All patients presented within the hours of 5:00 pm and 2:15 am. CONCLUSION: The majority of ED visits from an EDM festival were related to substance use. ED arrival times clustered during the evening and were associated with prolonged LOS. Few patients required hospital admission, but admitted patients required high levels of care. HCFs should use these data as a guide in planning for future events.

Digoxin-Specific Antibody Fragment Dosing: A Case Series.

Digoxin-specific antibody fragments (DSFab) are used for the treatment of poisoning by cardiac glycosides, such as pharmaceutical digoxin. Dosing of this therapy for chronic and acute poisonings is based on the steady-state serum concentrations of digoxin, historical data in acute ingestions, or empiric regimens purportedly based on the average requirements. Empiric dosing for adult patients involves utilization of 3-6 vials for chronic poisoning and 10-20 vials for acute poisoning. The aim of this study was to describe the average dosing requirements based on the steady-state serum concentration of digoxin or historical data and compare this with the empiric dosing regimens. We performed a retrospective analysis of cases over an 11-year period presented to the Illinois Poison Center where administration of DSFab was recommended. We identified 140 cases of chronic digoxin poisoning and 26 cases or acute digoxin poisoning for analysis. The average dose of DSFab recommended in the cases of chronic digoxin poisoning was 3.05 vials (SD ± 1.31). The average dose of DSFab recommended in the cases of acute digoxin poisoning was 6.33 vials (SD ± 5.26). These values suggest that empiric dosing regimens may overestimate the need for DSFab in cases of both chronic and acute poisonings of pharmaceutical digoxin.

Performance of International Classification of Disease-10 codes in detecting emergency department patients with opioid misuse.

BACKGROUND AND AIMS: Accurate case discovery is critical for disease surveillance, resource allocation and research. International Classification of Disease (ICD) diagnosis codes are commonly used for this purpose. We aimed to determine the sensitivity, specificity and positive predictive value (PPV) of ICD-10 codes for opioid misuse case discovery in the emergency department (ED) setting. DESIGN AND SETTING: Retrospective cohort study of ED encounters from January 2018 to December 2020 at an urban academic hospital in the United States. A sample of ED encounters enriched for opioid misuse was developed by oversampling ED encounters with positive urine opiate screens or pre-existing opioid-related diagnosis codes in addition to other opioid misuse risk factors. CASES: A total of 1200 randomly selected encounters were annotated by research staff for the presence of opioid misuse within health record documentation using a 5-point scale for likelihood of opioid misuse and dichotomized into cohorts of opioid misuse and no opioid misuse. MEASUREMENTS: Using manual annotation as ground truth, the sensitivity and specificity of ICD-10 codes entered during the encounter were determined with PPV adjusted for oversampled data. Metrics were also determined by disposition subgroup: discharged home or admitted. FINDINGS: There were 541 encounters annotated as opioid misuse and 617 with no opioid misuse. The majority were males (54.4%), average age was 47 years and 68.5% were discharged directly from the ED. The sensitivity of ICD-10 codes was 0.56 (95% confidence interval [CI], 0.51-0.60), specificity 0.99 (95% CI, 0.97-0.99) and adjusted PPV 0.78 (95% CI, 0.65-0.92). The sensitivity was higher for patients discharged from the ED (0.65; 95% CI, 0.60-0.69) than those admitted (0.31; 95% CI, 0.24-0.39). CONCLUSIONS: International Classification of Disease-10 codes appear to have low sensitivity but high specificity and positive predictive value in detecting opioid misuse among emergency department patients in the United States.

American College of Medical Toxicology Research Agenda 2024-2030.

ACMT recognizes the pivotal role of high-quality research in advancing medical science. As such, the establishment of a formal research agenda for ACMT is a leap forward in communicating the priorities of the College, its members, and the patient populations we serve. This thoughtfully crafted agenda will serve as a strategic compass for ACMT, guiding our pursuit of scientific discovery, fostering innovation, and enhancing outcomes for patients and communities affected by poisonings and exposures.

Tongue-type calcaneus fractures: a threat to skin.

Calcaneal fractures account for 60% of all tarsal bone fractures. Tongue-type calcaneus fractures are longitudinal fractures that exit the calcaneal tuberosity posteriorly and involve a portion of the articular surface. They are often superiorly displaced because of the insertion of the Achilles tendon and pull of the gastroc-soleus complex. Skin compromise complicates a large percentage of these injuries because of the thin layer of soft tissue and superficial nature of the fracture. Early recognition by the emergency physician and prompt operative repair prevent further injury and obviate the need for surgical soft tissue coverage or potential amputation.